THE  TRAINING  SCHOOLS  OF  THE 
FUTURE. 


BY  EDWARD  COWLES,  M.D., 

SUPERINTENDENT  OF  THE  MCLEAN  ASYLUM  FOR  THE  INSANE,  SOMERVILLE,  MASS. 

It  is  one  of  the  marvels  and  blessings  in  the  progress  of  the  pres- 
ent age  that  in  the  time  of  one  generation  so  great  and  universal  a 
reform  has  been  brought  about  as  that  in  the  nursing  of  the  sick.  It 
is  marvellous  also  that  so  good  a thing,  and  one  so  eagerly  accepted, 
should  have  waited  so  long  for  Florence  Nightingale  to  show  the 
world  its  need. 

The  history  of  all  this  has  become  household  words ; and  the  pur- 
pose of  this  paper  will  be,  not  so  much  to  dwell  upon  what  nursing- 
reform  has  already  so  nobly  achieved,  but  to  present  the  proposition 
that  we  are  as  yet  but  at  the  beginning  of  the  grand  results  of 
which  we  may  be  living  witnesses  if  we  will  only  put  our  hands  to 
the  work  in  the  right  way. 

There  is  no  longer  need  of  presenting  evidence  and  arguments  to 
show  that  the  trained  nurse  is  essential  to  a successful  hospital, 
her  value  to  both  patient  and  physician,  and  the  nobility  and  at- 
tractiveness of  her  calling  as  a profession  for  women.  It  is  only 
seventeen  years  since  general  hospital  training  schools  were  intro- 
duced into  this  country,  almost  simultaneously  at  the  Bellevue  Hos- 
pital, Massachusetts  General  Hospital,  and  the  New  Haven  Hospital, 
following  the  plan  of  Miss  Nightingale’s  St.  Thomas  Hospital  School. 
This  should  not  detract,  however,  from  the  great  credit  due  to  the 
New  England  Hospital  for  Women : at  its  foundation  in  1863,  one  of 
its  three  chief  objects  was  declared  in  the  by-laws  to  be  “ to  train 
nurses  for  the  care  of  the  sick.”  This  hospital  actually  graduated 
the  first  “ trained  nurses  ” educated  in  America.  Now  there  is  prob- 
ably no  one  of  our  hospitals  of  any  importance  that  does  not  have 
its  training  school  or  is  not  moved  by  the  question  of  adopting  the 


2 


school  system.  It  is  only  within  two  or  three  years,  however,  that 
this  could  be  said  of  a few  of  the  hospitals  for  the  insane ; for  it  is 
in  these  hospitals  that  even  now  there  is  but  the  beginning  of  as 
great  a reform  as  has  been  accomplished  in  the  general  hospitals. 
The  claim  of  the  insane  is  of  the  strongest  kind  for  the  blessing  of 
the  intelligent  nursing  that  it  is  perfectly  practicable  for  them  to 
have.  It  is  the  purpose  of  this  paper  to  emphasize  this,  and  to  urge 
the  importance  and  practicability  of  training  nurses  in  the  hospitals 
for  them,  not  only  for  their  immediate  benefit,  but  for  that  of  the 
country  at  large. 

The  adoption  of  the  training-school  system  in  the  general  hospitals 
of  many  cities  throughout  the  country  has  been  mentioned.  But 
though  the  system  has  been  successfully  and  very  usefully  extended 
to  the  smaller  hospitals,  now  becoming  so  common  in  the  larger 
towns,  there  is  still  a tendency  to  think  that  to  the  larger  hospitals  of 
the  great  cities  belongs  the  real  work  of  training  nurses,  while  the 
smaller  ones  — the  town  and  cottage  hospitals  — should  not  aspire 
to  the  pretension  of  having  training  schools.  Here  also  is  a point 
for  the  enlightenment  of  even  the  professional  mind  of  the  country. 

It  is  even  sometimes  said  of  the  schools  already  successfully  estabj 
lished  that  their  work  will  soon  be  overdone  and  the  market  over l 
stocked  with  their  graduates.  The  time  has  passed  for  pessimistii 
obstructionists  to  say,  “ You  cannot  find  women  enough  who  want  to 
be  nurses,” — “They  will  not  find  employment  when  they  are 
trained,”  — or,  worst  saying  of  all,  “ They  will  leave  your  hospitals 
and  asylums  as  soon  as  they  are  trained,  and  you  will  get  no  good 
from  your  labor  with  them.” 

All  such  conceptions,  that  limit  the  active  promotion  of  this  great 
reform,  arise  from  too  narrow  a view  of  its  importance  and  its  scope. 
The  simple  truth  is  that,  aside  from  their  service  in  the  hospitals, 
trained  nurses  are  yet  so  few  in  number  that  they  are  practically 
luxuries  for  the  well-to-do,  in  private  life.  It  is  a matter  of  supply 
and  demand.  The  supply  must  first  create  the  demand,  and,  the  value 
of  such  nurses  being  made  known,  then  the  demand  will  call  forth 
the  adequate  supply  for  the  larger  needs  of  the  country  in  general. 
These  reactions  of  a gradually  increasing  demand  and  supply  will  be, 
accompanied,  in  due  time,  by  a reduction  in  the  cost  of  the  service  of 
such  nurses.  This  is  an  important  factor  in  the  extension  of  their  ^ 
usefulness.  They  ought  not  only  to  be  as  common  in  every  country 
town  and  village  as  physicians  are,  but  there  should  be  many  more 


310.13 

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3 


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of  them.  This  is  the  ideal  condition  to  which  we  should  aim  ; and 
every  hospital  in  the  land,  whether  large  or  small,  general  or  special, 
as  for  the  care  of  the  insane,  may  educate  nurses  for  its  own  pur- 
poses, and  at  the  same  time  find  its  own  advantage  in  supplying  the 
public  need  of  its  own  vicinity.  All  the  graduates  that  all  can  pro- 
duce may  be  sent  out  without  overrunning  the  field  for  their  employ- 
ment, and  the  schools  in  the  great  hospitals  may  become  largely  the 
normal  or  higher  schools  of  nursing. 

These  may  seem  to  be  visionary  statements:  their  truth  can  be 
shown  by  a consideration  of  some  of  the  elements  of  this  great 
reform  now  but  fairly  begun.  The  movement  is  still  at  the  stage  in 
which  the  supply  is  creating  the  demand.  Comparatively  few  people 
in  the  great  population  of  this  country  yet  have  any  adequate  knowl- 
edge of  the  value  of  skilled  nursing,  and  the  large  majority  have  not 
the  means  of  obtaining  that  boon  of  which  they  ought  to  have  the 
benefits.  The  work  of  the  Boston  Directory  for  Nurses,  which  is  a 
central  point  in  this  regard  for  all  of  New  England,  goes  to  prove 
the  truth  of  these  statements ; and  it  is  of  great  interest  as  exemplify- 
ing the  process  of  evolution  of  this  beneficent  reform.  In  its  exist- 
ence of  eleven  years,  to  September,  1889,  the  results  accomplished 
by  the  directory  may  be  represented  in  gross  as  follows : * — 


Total  number  of  nurses  registered  in  eleven  years, 969 

Total  nominally  available,  September,  1889:  — 

Male  nurses, 84 

Non-graduate  female  nurses, 426 

Graduate  female  nurses, 315 

Masseuses, 14  839 


v 


The  average  registration  is  about  100  per  year.  The  “casualties  ” 
of  the  last  of  the  period  of  eleven  years  were  29.  The  average  net 
increase  for  several  years  has  been  about  50  per  year,  and  the  propor- 
tional number  of  trained  nurses  registered  has  increased  relatively 
to  the  untrained.  The  “casualties,”  however,  for  the  last  year 
included  only  two  deaths.  Other  nurses  married  or  left  the  profes- 
sion temporarily  or  permanently  for  various  reasons  ; but  they  were 
not  lost  to  the  cause,  as  they  carried  their  valuable  knowledge  and 
experience  into  domestic  and  other  relations,  where  they  are  calcu- 
lated to  be  always  useful.  The  annual  increment  of  fifty  nurses  per 
year  in  the  directory  comes  chiefly,  of  course,  from  the  larger  hos- 

* Compare  article  “Nursing  Reform  for  the  Insane,”  A merican  Journal  of  Insanity,  October, 
1887,  by  the  writer  of  this  paper. 


4 


pitals  of  the  vicinity, — the  New  England  Hospital  for  Women,  Mas- 
sachusetts General  Hospital,  Boston  City  Hospital  and  Lying-in 
Hospital,  and  McLean  Asylum.  The  product  of  all  these  is  about 
eighty  nurses  per  year.  There  are  also  among  those  registered  in 
the  Directory  representatives  of  the  general  hospitals  at  Portland, 
Lowell,  Lawrence,  Providence,  New  Bedford,  and  New  Haven,  and 
a few  from  outside  of  New  England.  All  of  these  hospitals,  of 
course,  chiefly  furnish  nurses  for  their  own  immediate  vicinities. 
Some  of  the  other  new  hospitals  recently  established,  or  now  under 
construction  or  projected,  in  Eastern  New  England  are  at  Hanover, 
Concord,  Manchester,  Portsmouth,  Lawrence,  Malden,  Lynn,  Cam- 
bridge, Newton,  Waltham,  Framingham,  Worcester,  Quincy,  Taunton, 
Woonsocket,  and  Newport.  There  are  doubtless  others,  for  this  list 
is  not  pretended  to  be  complete. 

The  Boston  Directory  (notwithstanding  its  increase  of  business) 
finds  therefore  a cessation  of  calls  from  all  such  new  centres  of  self- 
supply as  they  become  established.  Its  work  of  the  last  year  shows 
the  growing  preference  for  trained  nurses,  of  whom  271  were  given 
employment,  while  only  170  non-graduates  were  accepted  by  appli- 
cants for  nurses.  Only  five  men  were  found  employment  during  the 
year.  Some  further  indications  are  most  significant.  The  rate  paid 
to  trained  female  nurses  was  in  the  first  years  quite  uniformly  $15 
per  week,  with  somewhat  more  for  nursing  male  patients.  Three 
years  ago  it  was  thought  that  the  increasing  supply  would  soon  lower 
the  rates ; but,  on  the  contrary,  a common  charge  is  now  $21  and  $25 
per  week  by  experienced  nurses,  and  the  former  rate  is  largely  limited 
to  recent  graduates  or  the  untrained.  Male  nurses  commonly  receive 
$4  and  $5  per  day.  These  figures  sustain  the  statement  that  in  New 
England  the  demand  is  increasing  faster  than  the  supply,  and  the 
hospital  trained  nurse  is  still  a luxury  really  beyond  the  means  of 
the  great  masses  of  people.  There  ought  to  be  more  nurses,  and 
good  ones  should  be  had  at  much  less  cost.  It  is  estimated  that  in 
Great  Britain  there  are  fifteen  thousand  to  twenty  thousand  trained 
nurses  in  the  profession,  and  it  is  no  bar  to  their  continued  produc- 
tion by  the  hospitals.  When  will  America  be  supplied  in  like  pro- 
portion ? 

Let  us  now  consider  the  future  of  the  profession  of  nursing.  Its 
usefulness,  as  already  demonstrated,  indicates  what  it  may  be  when 
there  is  a general  diffusion  of  its  services  throughout  the  country. 
Let  it  be  supposed  that  the  ideal  conditions  to  which  we  should  aim 


5 


have  been  attained, — it  may  be  more  than  one  generation  hereafter, 
— and  that  intelligent  and  skilled  nursing  is  available  for  all  the  sick. 
We  may  consider  first  what  will  be  the  nature  of  its  benefits,  and 
next  how  they  are  to  be  attained.  

The  value  of  an  intelligent,  instructed  nurse  is  now  too  obvious  to 
need  statement  here.  Every  physician  who  knows  about  it  would  be 
glad  to  have  such  nursing  for  every  one  of  his  patients,  poor  as  well 
as  rich.  Should  such  a condition  of  things  ever  come  about,  it  would 
mean  that  commonly  throughout  the  country  there  will  be  nurses 
practising  their  profession  as  such,  there  will  be  married  women  who 
have  had  special  training  as  nurses,  there  will  be  single  women  whose 
home  duties  have  called  them  away  from  the  active  practice  in  the 
larger  towns  of  the  profession  in  which  they  are  skilled,  and  they 
will  be  the  neighborhood  nurses.  It  goes  without  saying  that  the 
cause  of  preventive  medicine  will  thus  be  advanced  most  effectively 
beyond  anything  we  can  now  conceive,  not  only  in  general  hygiene, 
but  in  all  that  pertains  to  the  early  recognition  of  disease  in  general 
medicine,  and  as  well  of  the  requirements  in  mental  hygiene  and  the 
protection,  care,  and  treatment  of  the  insane.  Does  this  picture  of 
a future  Utopia  appear  more  impossible  of  realization  than  it  would 
have  seemed  for  our  fathers,  in  the  first  half  of  the  present  century, 
to  have  been  told  of  what  Florence  Nightingale’s  reform  has  already 
done  for  us?  Certainly,  these  considerations  show  that  there  will  be 
ample  room  for  a general  diffusion  of  all  knowledge  that  training  in 
nursing  implies.  This  is  the  very  reason  for  being  of  the  Emergency 
and  Hygiene  Associations,  that  are  so  zealously  beginning  their 
work  in  the  instruction  of  the  general  public.  All  these  efforts  are 
calculated  to  do  great  good,  and  should  be  fostered  in  every  way. 
They  reach,  along  their  own  peculiar  lines,  results  that  cannot  other- 
wise be  attained.  They  educate  the  people  to  see  the  need  of  educa- 
tion in  such  matters.  Every  such  movement  will  find  its  true  prov- 
ince in  the  later  adjustments  that  must  come  of  the  relations  of  all 
the  newly  organized  forces  that  are  working  for  the  general  good. 

Having  set  forth  the  possible  benefits  that  may  be  hoped  for,  it 
must  now  be  shown  how  they  are  likely  to  be  attained.  The  ele- 
ments of  the  problem  must  first  be  considered.  Of  course  the 
methods  of  procedure,  in  the  future  progress  of  the  reform,  must 
be  an  evolution  from  and  an  improvement  upon  what  has  already 
been  done.  A study  of  these  results  and  the  processes  by  which  they 
have  been  gained  reveals  two  fundamental  principles  essential  to 


6 


practical  success.  It  is  rather  that  these  principles  have  had  room 
to  work  freely  than  that  they  have  been  fully  recognized.  They 
are  : (i)  The  giving  to  the  nurse  sufficient  knowledge  of  disease  to 
teach  her  what  to  do,  and  thereby  arousing  the  professional  spirit 
and  giving  intelligent  play  to  the  sympathetic  feelings  of  the  woman. 
(2)  The  stimulation  of  a wholesome  self-interest,  by  showing  that  in 
a respectable  and  philanthropic  calling  she  may  honorably  support 
herself  and  get  means  to  help  those  dear  to  her,  as  is  her  duty.  The 
progress  of  the  reform,  in  a material  degree,  has  been  dependent 
upon  this  natural  element  of  self-help  in  human  nature  and  our  social 
conditions. 

Now,  any  hope  that  we  may  have  of  furthering  this  reform  and  en- 
larging its  scope  must  depend  upon  our  recognition  and  careful 
observance  of  these  two  principles.  We  may  make  use  of  them 
to  attain  philanthropic  ends.  We  may  accept  self-sacrifice  in  a good 
cause  and  the  exercise  of  the  missionary  spirit,  when  they  come  to 
our  aid;  and  we  do  find  both  of  these  wonderfully  developed,  in- 
cidentally to  the  business  of  nursing  the  sick  and  the  insane.  We 
may  stimulate  and  exalt  to  a great  degree  in  some  persons  the  altru- 
istic element  in  this  professional  service,  but  this  philanthropy  must 
J^e  worked  by  human  instruments  that  must  live.  From  the  foregoing 
considerations  it  follows  therefore  that,  if  we  would  have  intelligent 
and  proper  service  for  the  sick  in  any  hospital  or  anywhere,  it  must 
be  by  instructing  intelligence  in  the  special  work.  Almost  everybody 
knows  this  well  enough  now.  But,  moreover,  we  must  see  to  it  that 
to  every  individual  so  employed  there  must  be  held  up  the  possibility 
of  gaining  something  desirable  beyond  the  doing  of  the  service  we 
ask : there  must  be  a forecast  of  a profitable  or  satisfactory  self-sup- 
porting occupation.  This  is  the  principle  that  is  not  yet  sufficiently 
recognized.  So  far  in  the  history  of  nursing-reform  the  two  prin- 
ciples stated  have  really  had  free  play  and  effect, — admitting,  of 
course,  the  pure  philanthropy  of  those  who  have  had  to  inaugurate 
and  conduct  the  organizations  through  which  alone  systematic  instruc- 
tion can  be  given  to  those  who  are  to  render  the  personal  services 
required  by  this  profession.  The  facts  of  the  inducements  of  lucrative 
work  and  personal  credit  have  been  the  potent  forces  that  have  given 
the  reform  its  vitality  and  its  momentum.  Philanthropy  is  best  gain- 
ing its  ends  by  making  use  of  these  inducements.  It  is  entirely  right 
that  these  motive  influences  should  continue  to  operate,  and  that  the 
highly  trained  nurses  of  the  great  hospitals  should  mainly  serve  the 


7 


wealthier  classes  and  be  well  paid  for  such  service,  or  become 
teachers  of  others  and  be  well  rewarded  for  their  especially  skilled 
labors.  The  missionary  spirit  abounds  among  them  in  a due  degree 
it  is  true,  and  finds  its  fields  in  continued  hospital  service,  in  district- 
nursing, and  the  like ; but  there  is  no  law  nor  sentiment  by  which 
skilled  nurses  may  be  required  to  abate  anything  of  their  wage-earn- 
ing power  in  performing  poorly  rewarded  labor,  from  a professional 
point  of  view.  We  may  ask  them  to  give  as  we  give.  For  sweet 
charity’s  sake  they  do  much  : let  no  one  say  anything  in  qualification 
of  this.  But,  as  a practical  business  matter,  we  must  provide  otherwise 
for  that  greater  part  of  the  world’s  nursing  which  can  only  be  had 
when  afforded  at  a moderate  cost  to  those  who  receive  the  service, 
and  by  those  who  give  it.  There  is  no  derogation,  in  these  state- 
ments, of  the  nobility  of  the  profession  of  nursing.  Let  us  claim  for 
it  the  same  kind  of  nobility  that  is  accorded  to  the  medical  profession. 
Let  both  professions  make  their  own  living.  Those  who^are  engaged 
in  promoting  charitable  works  will  greatly  magnify  the  results  they 
gain,  by  as  much  as  they  contrive  to  make  those  results  incidental  to 
the  labors  of  a self-supporting  calling.  The  physician  finds  his  school 
in  the  hospital  and  the  dispensary  district,  and  gives  nobly  of  his 
services  to  the  poor.  May  not  the  nurse  so  combine  her  schooling 
and  charity-giving? 

A broad  estimate  might  be  made,  by  way  of  illustration,  of  the  pro- 
portional relations  between  the  different  kinds  of  nursing  service 
which  are  required  in  the  broad  field  that  waits  for  it,  based  upon  the 
differences  of  training,  of  compensation,  and  of  ability  of  people  to 
pay.  It  might  be  said  that  one-tenth  of  all  the  future  nursing  will  be 
done  for  the  wealthy  classes  by  nurses  trained  in  the  great  hospitals; 
two-tenths  will  be  done  for  the  poor  within  the  hospitals ; and  two- 
tenths  will  be  done  for  the  poor  in  dispensary  and  district  work.  The 
remaining  five-tenths  will  have  to  be  done  at  moderate  rates,  and 
chiefly  by  nurses  trained  in  the  small  hospitals,  or  otherwise.  This 
training  must  be  done  largely  in  the  country  towns,  in  the  presence 
of,  and  in  exact  adaptation  to,  the  work  and  the  conditions  under 
which  it  is  to  be  done.  The  first  three-tenths,  including  the  well- 
to-do  and  the  poor  in  hospitals,  according  to  this  enumeration,  will 
be  sufficiently  well  provided  for  by  the  present  established  systems 
in  the  great  hospitals.  The  district  charity  or  dispensary  service 
must  have  greatly  enlarged  and  more  effective  methods  to  accomplish 
the  work  that  lies  before  it.  In  fact,  this  work  has  only  yet  been 


tentatively  attempted.  There  remains  the  large  field  of  city  nursing 
at  moderate  cost,  and  that  in  the  country  districts,  for  which  there 
will  be  necessary  larger  sources  of  supply.  There  must  be  a special 
evolution  of  methods,  of  which  there  has  not  been  until  recently  any 
adequate  conception. 

It  has  been  set  forth  as  one  of  the  main  propositions  of  this  pres- 
ent writing  that  by  far  the  larger  part  of  the  field  to  be  covered 
by  this  eminently  philanthropic,  life-saving,  disease-preventing  reform 
has  as  yet  received  no  proper  recognition,  the  importance  of  which  it 
is  desired  here  to  emphasize.  Now,  this  discussion  comes  to  the 
chief  point  of  our  inquiry,  as  to  how  we  may  conceive  it  possible  to 
accomplish  practically,  without  too  great  labor  and  cost,  the  raising 
up  of  a self-supporting  nursing  force  for  the  general  service  of  the 
country  at  large.  There  have  now  been  established  in  America,  with 
the  proof  of  demonstration,  the  beginnings  of  two  movements  des- 
tined to  have  a large  influence  in  working  out  the  extensive  results 
here  pictured  as  so  desirable.  These  two  methods  are  shown  to  be 
ready  at  our  hands  for  the  practical  carrying  on  of  this  great  pur- 
pose, on  a larger  and  more  effective  scale  than  ever  before,  with  the 
incidental  accomplishment  of  the  strictly  charitable  work  of  nursing 
the  poor  that  it  is  found  so  difficult  to  establish.  These  two  methods 
are : — 

1.  A distinctly  new  system  of  training  in  general  nursing. 

2.  The  great  work  of  training  nurses  of  which  the  hospitals  for  the 
insane  are  easily  capable. 

i.  The  new  system  of  training  nurses  may  now  be  considered. 
The  general  extension  of  the  present  school  system,  even  as  it  is  put 
in  practice  in  New  England  with  all  its  hospitals,  as  has  been  de- 
scribed, cannot  supply  the  great  field  of  common  nursing,  so  to 
speak,  that  has  its  strongest  claims  upon  the  general  physicians,  who 
practise  among  the  poor  or  those  of  moderate  means,  either  in  town 
or  country.  To  discover  a system  of  training  nurses  for  this  service 
that  will  even  only  largely  aid  in  accomplishing  the  important  results 
so  much  to  be  desired  is  to  make  an  epoch  in  the  evolution  of 
modern  progress.  It  is  inspiring  to  recognize  the  fact  that  such  a 
discovery  has  been  made  and  its  value  demonstrated  within  the  last 
five  years.  It  has  been  admirably  described  as  “A  New  Way  of 
Training  Nurses”  in  a little  book  bearing  that  title,*  by  Alfred 


Published  in  Boston.  Cupples  & Hurd.  1888. 


9 


Worcester,  M.D.,  to  whom  the  credit  is  due  of  devising,  and  inaugu- 
rating the  system  in  the  Waltham  Training  School  for  Nurses,  at 
Waltham,  Mass.  The  great  merits  of  the  system  are  its  simplicity, 
ease  of  organization,  elasticity  of  adaptation  to  large  or  small  require- 
ments, effectiveness,  and  the  fact  that  it  can  be  put  into  operation 
in  anv  large  or  small  city  or  town  of  a few  thousand  inhabitants, 
where  a few  physicians  will  co-operate  in  giving  the  required  lectures. 
Above  all,  it  is  unique  in  that  it  needs  no  hospital  as  a foundation , while 
yet  it  may  be  an  adjunct  and  an  aid  to  the  support  of  one ; and  in 
that  it  is  self-supporting,  or  even  more  than  that,  under  favorable  cir- 
cumstances. The  poor  of  the  community  are  nursed  without  charge 
or  at  very  low  rates ; the  well-to-do  have  nursing  as  good  as  any ; 
night  watchers  and  day  nurses,  by  the  hour,  day,  or  week,  can  be 
furnished  on  call  for  all  the  country  round.  If  any  one  be  sceptical 
as  to  any  part  of  this,  let  him  read  the  book  and  visit  Waltham, — it 
is  the  only  place  in  the  world  where  such  a thing  can  be  seen, — and 
the  truth  of  all  that  is  here  said  of  it  will  be  accepted. 

The  history  of  this  School  is  most  interesting  and  instructive. 
Every  one  interested  in  these  matters  should  read  Dr.  Worcester’s 
entertaining  book,  noting  that  the  most  telling  results  have  come  to 
pass  in  the  two  years  since  it  was  published.  He  had  been  familiar 
with  good  nursing,  and  knew  by  experience  how  to  teach  ordinary 
young  women  to  be  excellent  lying-in  nurses.*  This  caused  an  inten- 
sification of  some  trying  experiences  with  the  old-style  nuVse.  He 
conceived  it  to  be  the  “physician’s  duty  not  only  to  give  proper  direc- 
tions for  the  management  of  every  patient  under  his  charge,  but  also 
to  see  that  his  orders  are  intelligently  obeyed.”  “ There  is  no  ex- 
cuse,” he  says,  “ in  the  fact  that  trusty  agents  are  not  at  his  hand,  for 
it  is  his  business  to  provide  them  ; and,  until  he  can  be  sure  of  intelli- 
gent, faithful  nursing  service,  he  must  not  undertake  the  management 
of  more  cases  of  sickness  than  he  can  in  person  superintend.”  This 
is  a high  conception  of  a physician’s  responsibility,  but  it  determined 
the  effort  to  have  instructed  nurses  in  all  cases.  But  only  the  rich 
could  afford  the  city-trained  nurse,  and  Dr.  Worcester’s  problem  was 
“ to  demonstrate  the  way  in  which  the  supply  of  trained  nurses  can 
be  so  increased  that  their  services  may  be  had  in  every  village  of  the 
land.”  His  conclusion  was  that,  “in  the  smaller  towns  and  villages, 
the  physicians,  if  they  desire  the  great  advantages  of  this  new  dispen- 


* “ Monthly  Nursing.”  Lectures  given  to  nurses  at  the  Boston  Lying-in  Hospital.  By  A. 
Worcester,  M.D.  Boston,  1886. 


IO 


sation,  must  train  their  own  nurses .”  He  believed  that  “ there  would 
be  no  trouble  in  finding  young  and  strong  women  well  fitted  and  eager 
for  such  training.”  There  was  no  hospital  in  Waltham  ; but  interest 
was  aroused,  a plan  adopted,  and  a school  organized  with  seven  pupils 
in  1885,  the  method  being  “based  upon  the  facts,  first,  that  nurses 
can  be  well  trained  in  private  practice  outside  of  hospital  walls ; and, 
second,  that  excellent  service  is  given  by  the  student-nurses  during 
their  course  of  training.”  It  was  a recourse  to  the  old  way  of  train- 
ing physicians  by  accompanying  their  preceptors  in  their  general 
practice,  except  that  by  this  method  the  nurses  can  be  trained  in  all 
they  need  to  know. 

The  responsibility  of  the  School  was  assumed  by  the  lady  man- 
agers. Some  money  was  raised  by  donations  for  the  first  expenses. 
Rooms  were  obtained  for  a headquarters,  where  the  nurses  could 
board  when  not  on  duty,  and  go  to  receive  their  daily  instruction  at 
the  regular  afternoon  lesson  hour.  A trained  nurse  was  employed  to 
be  superintendent,  to  manage  the  School,  conduct  class  exercises, 
and  visit  particular  cases,  when  need  be,  where  the  student-nurses 
were  employed.  A two  years’  course  of  instruction  was  prescribed. 
Brief  courses  of  lectures  were  given  by  a few  physicians.  The  stu- 
dent-nurses of  the  first  year  did  service  gratuitously  or  for  small 
compensation  for  the  patients  of  these  physicians.  The  second  year 
students  were  sent  out  upon  the  call  of  any  physician,  as  in  some  of 
the  general  hospitals.  And  the  School  prospered, — unlike  many 
other  reforms,  paying  its  own  way. 

The  charge  for  student  nurses  of  the  first  year  is  $1.25  per  day,  or 
$7  per  week,  and  board;  of  the  second  year,  $1.50  per  day,  or  $10 
per  week.  When  it  is  not  convenient  for  the  family  to  furnish  board, 
it  is  provided  at  the  School  at  an  additional  charge  of  fifty  cents  per 
day.  The  School  pays  the  pupils  $9  and  $12  per  month  for  the  first 
and  second  years  respectively,  and  is  supported  by  the  income,  with 
a balance  of  profit.  The  donations  for  the  first  year  amounted  to 
$2 33  ; for  the  last  of  the  five  years,  $55.  The  expenses  of  the  first 
year  were  $1,051;  for  the  last  year,  $4,952.  The  earnings  for  the 
first  year  were  $888 ; for  the  last  year,  $5,748.  There  is  now  a bal- 
ance in  the  treasury  of  over  $1,000.  The  School  occupies  a dormi- 
tory building,  with  class-room,  and  pays  an  annual  rental ; but  the 
building  has  been  completely  furnished  by  the  School,  at  an  expense 
exceeding  the  entire  amount  of  the  donations.  Dr.  Worcester  writes: 
“ The  total  of  donations  is  less  than  the  outlay  in  permanent  fittings ; 


and,  after  the  end  of  the  second  year,  the  yearly  donations  amounted 
to  less  than  the  balance  carried  forward  to  the  School’s  credit. 
Indeed,  after  the  second  year,  they  came,  in  spite  of  our  protest  that 
we  needed  nothing ; but  the  donors  insisted  on  continuing  the  charity 
we  originally  asked  for.  Instead  of  asking  for  money  outright,  we 
asked  for  money  for  charity  nursing ; that  is,  we  asked  Mrs.  S.  to 
give  to  the  nursing  of  Mrs.  B.,  and  so  on.  Now  we  can  do  all  of  the 
charity  nursing  without  extra  help,  our  earnings  being  so  largely  in 
excess  of  our  expenses.”  From  this  it  appears  possible  to  establish 
such  a school  by  making  an  investment  in  the  plant,  and  having  it 
repaid  in  a few  years ; but  of  course  it  is  best  to  organize  in  a small 
way  upon  donations,  and  incur  no  debts. 

The  School  has  graduated  three  classes  of  nurses, — a total  of 
twenty-five  ; and  there  are  as  many  more  now  engaged  in  the  work  as 
pupils.  Some  of  these  graduates  have  continued  in  its  service  for 
a time,  and,  with  the  student-nurses,  have  done  a large  amount  of 
work  in  all  the  country  round,  at  the  rates  before  stated,  together 
with  a great  deal  of  charity  work,  whenever  or  wherever  it  was 
needed,  on  the  call  of  any  one  of  the  physicians  of  the  School. 
Their  especial  training  in  home-nursing  makes  these  nurses  especially 
acceptable  to  families  and  physicians.  They  say,  “Better  nurses 
cannot  be  found.”  It  is  an  inspiration  to  witness  their  love  of  work 
among  the  poor.  The  amount  of  the  service  the  School  has  rendered 
is  indicated  by  the  record  of  the  employment  of  the  nurses.  In  the 
first  year,  it  was  1,027  days  5 'm  the  ^ast  the  five  years,  5,378  days, 
or  78  per  cent,  of  all  the  days  for  which  there  were  nurses  ready  for 
service.  The  demand  for  these  nurses  is  rapidly  increasing  in  the 
towns  about  Waltham.  At  the  Boston  Directory  is  noted  an  absence 
of  calls  from  this  section.  The  class  of  the  coming  year  is  to  be 
of  twenty  pupils, — nearly  double  the  number  of  any  previous  year. 
A very  significant  circumstance  is  the  fact  that  a number  of  the  grad- 
uate nurses  have  been  most  acceptably  employed  in  some  of  the 
small  hospitals  of  this  section  of  the  State  as  being  well-qualified 
nurses.  Another  significant  fact  is  in  proof  of  the  statements  here 
made  as  to  the  demand  for  such  nurses.  The  earlier  graduates  of 
this  School  now  command  the  higher  compensation  equal  to  that  re- 
ceived by  the  city-trained  nurses.  This  is  good.  It  stimulates  the 
progress  of  the  cause. 

A small  hospital  is  an  outgrowth  of  these  conditions ; but  it  is  an 
independent  establishment,  and  pays  the  School  for  the  service  of 


12 


those  nurses  it  employs  at  cost,  and  at  the  same  time  it  furnishes 
a valuable  adjunct  to  the  means  of  training.  But  the  success  of  the 
School  was  established  without  the  hospital. 

While  this  system  includes  the  method  of  outside  pay  service 
adopted  by  some  of  the  general  hospitals  in  the  second  of  their  school 
years,  and  while  it  is  practised  to  some  extent  by  the  “ Deaconess 
Houses,”  or  orders  of  nursing  sisterhoods,  where  there  are  lim- 
itations to  expansion,  it  is  obvious  that  an  underlying  principle 
has  here  an  original  and  unique  application.  It  is  the  principle  of 
the  conservation  of  values  : the  knowledge  of  the  physician  has  a 
value ; this  is  multiplied  by  imparting  it  to  a class  of  nurses ; they 
turn  it  into  money  in  a ready  market  plus  a large  amount  of 
gratuitous  nursing  service  enjoyed  not  only  by  those  unable  to  pay 
for  it,  but  also  by  the  physicians  and  their  families ; the  money 
earned  pays  the  expenses  of  the  establishment.  Putting  together  the 
first  and  last  terms  in  this  sequence  of  elements  of  the  system,  the 
lady  managers,  giving  freely  of  their  time  and  effort,  get  their  rich 
return  in  the  large  amount  of  charity  nursing  accomplished ; ttie 
physicians  for  a little  time  and  effort  are  repaid  many  times  over  by 
the  better  nursing  of  their  patients  ; the  nurses  pay  for  their  education 
by  giving  their  time  and  service,  and,  when  all  is  done,  they  have  a 
self-supporting  profession  ; the  public  has  brought  within  its  reach 
and  means  good  nursing,  for  which  it  is  glad  to  pay. 

It  is  easy  to  see  how  a small  hospital  can  make  profit  to  itself  and 
fulfil  a plain  duty  to  its  surrounding  community  by  adapting  this  plan 
to  its  own  needs.  But,  if  a school  is  to  be  attempted  in  such  a hos- 
pital, it  should  have  a competent  and  well-paid  head,  who  is  capable 
of  overcoming  the  narrow  limitations  of  the  field  of  instruction. 
By  using  the  Waltham  plan  there  will  be  a greater  variety  of  prac- 
tical work,  and  the  teaching  may  be  so  developed  as  to  turn  out 
really  educated  nurses.  Then  more  women  will  be  trained,  more 
nursing  will  be  done  for  the  public  that  supports  the  hospital,  and 
more  interest  will  be  taken  in  it  because  of  the  greater  good  received 
from  it.  In  a section  of  a large  city,  such  a school  for  “teaching 
nurses  in  private  practice,”  or  “ home-nursing,”  may  be  established. 
A prime  point  is  not  to  proclaim  its  object  as  charity  nursing, — 
that  would  repel  the  people  who  like  to  pay  and  from  whom  the 
school  must  get  its  support : the  charity  work  will  be ^ done  inci- 
dentally,— it  will  actually  be  wanted  as  largely  the  T>asis  of  \he 
teaching.  The  organizations  for  “District  Nursing”  may  find  their 


3 


field  and  their  usefulness  enlarged  by  turning  their  attention  directly 
to  the  training  of  nurses  by  means  of  their  charity  work.  The  Visit- 
ing Nurse  Society  of  Philadelphia  is  making  an  interesting  adaptation 
of  this  system. 

The  population  of  Waltham  was,  in  1888,  about  16,000.  It  is  evi- 
dent that  in  a smaller  town  this  training-school  system  would  work 
successfully  on  a smaller  scale.  There  is  enough  in  the  experience 
of  the  Waltham  School  to  show  that  there  would  be  a ready  absorp- 
tion of  a large  amount  of  nursing  work  under  similar  conditions. 
Even  there,  five  years  ago,  there  was  at  first  little  faith,  other  than 
Dr.  Worcester’s,  that  there  was  any  place  for  such  work  there.  The 
Waltham  system  has  demonstrated  itself  as  an  admirable  and  effi- 
cient contribution  to  the  urgent  needs  of  the  time. 

Large  credit  and  gratitude  are  due,  and  will  in  time  be  abundantly 
given,  to  Dr.  Worcester  for  his  happy  inspiration,  to  the  lady  man- 
agers who  have  done  so  much  to  aid  in  working  out  the  plan  of  the 
School  so  that  others  have  only  to  follow  their  leading,  and  to  Miss 
Hackett,  its  superintendent,  who  has  largely  shared  in  making  it  suc- 
cessful. 

2.  It  remains  to  speak  briefly  of  the  claim  of  the  public,  in  the 
country  at  large,  upon  the  hospitals  for  the  insane  for  the  great  work 
of  which  they  are  capable.  The  general  adoption  of  the  Waltham 
system,  for  training  in  “ Home  ” and  “ Visiting  Nursing,”  easy  as  it 
is  to  organize,  now  that  the  way  is  shown,  depends  still  upon  the 
voluntary  efforts  of  wide-awake  people  in  all  the  eligible  localities 
throughout  the  whole  land.  It  would  be  long  waiting  in  some  parts 
of  our  great  country  for  this  New  England  notion  to  become  per- 
vasive. But  the  hospitals  for  the  insane  are  well-organized  establish- 
ments, and  well  distributed  among  the  population  of  the  various 
States.  There  is  no  one  thing  that  could  now  be  done  in  regard  to 
them  that  will  yield  so  much  direct  benefit  to  the  patients,  profit 
to  the  hospitals  in  furthering  their  prime  purpose  of  curing  the  sick, 
and  benefit  to  the  State  in  promoting  the  welfare  of  its  citizens  by 
the  diffusion  among  them  of  this  education,  as  the  establishment  of 
such  schools  in  all  such  hospitals.  They  would  be  educational,  in 
the  strictest  sense  of  the  word.  As  a means  of  mental  training  of 
the  young  men  and  women  in  regular  class  recitations,  in  the  taking 
down  and  writing  out  of  notes  of  lectures  and  of  original  reports  of 
cases,  and  in  the  acquirement  of  useful  knowledge,  such  schools  are 
like  high  schools.  They  have  the  claim  of  industrial  schools : they 


would  give  special  training,  not  only  in  a useful  business,  but  one 
that  has  a special  economic  value  to  the  State  in  the  prevention  of 
disease,  besides  the  amelioration  and  abbreviation  of  disease.  They 
have  also  the  claim  of  normal  schools : they  would  produce  the 
teachers  for  smaller  local  schools,  besides  diffusing  instruction  upon 
the  most  vital  matters.  They  are  entitled  to  the  fostering  care  and 
support  of  the  State.  But  this  need  not  be  directly  claimed  : the 
insane  in  the  hospitals  are  entitled  to  the  benefits  that  modern 
enlightenment  in  these  matters  brings.  The  State  has  a right  to 
such  returns  for  money  spent  upon  its  hospitals ; but  let  it  be  liberal 
to  the  nursing  service.  The  added  expense  of  schools  in  such  hospi- 
tals is  relatively  very  small : it  would  be  money  well  spent  if  the 
expense  were  much  greater  than  it  need  be  to  introduce  and  carry  on 
this  reform.  It  makes  a true  hospital  of  every  asylum  in  which  such 
training  of  nurses  is  done.  The  medical  staff  that  joins  in  the  teach- 
ing is  directly  benefited  and  made  more  efficient  by  such  a duty. 
He  who  teaches  learns. 

General  nursing  can  be  well  taught  in  hospitals  for  the  insane : 
that  is  proved  by  the  last  eight  years’  work  of  the  McLean  Asylum 
'Training  School  for  Nurses,  with  its  92  graduates,  including  20  men, 
representing  some  of  the  earliest  work  in  the  training  of  male  nurses. 
The  annual  product  will  hereafter  be  20  to  30  nurses;  ten  or  twelve 
of  these  each  year  will  be  men.  The  graduates  of  the  McLean 
Asylum  School  have  acquitted  themselves  well  in  general  nursing  in 
private  families,  in  competition  with  the  highly  trained  nurses  of  the 
city  schools. 

In  the  establishment  of  Asylum  Schools,  the  two  fundamental 
principles  should  never  be  forgotten  : — 

1.  The  nurses  should  be  given  a full  course  of  didactic  instruction 
in  general  nursing,  and  as  much  as  possible  of  practical  work.  It  is 
remarkable  how  effective  a use  can  be  made  of  the  conditions  of  an 
asylum  truly  hospitalized.  The  truth  is  that  a large,  well-organized 
asylum  has  some  positive  advantages  in  this  regard  over  the  small 
general  hospital. 

2.  The  plan  of  training  should  include  the  intention  of  making  the 
pupils  successful  in  private  nursing  among  the  people  from  whom 
they  come.  Even  in  a population  with  limited  means,  the  people  will 
attach  a special  value  to  the  service  of  the  instructed  nurse  ; and  her 
knowledge  will  thereby  increase  her  power  of  self-support  relatively 
to  that  of  other  members  of  the  community  in  which  she  lives. 


i5 


The  question  of  thoroughness  of  training  is  a most  important  one. 

No  disregard  of  that  should  be  implied  by  this  advocating  of  such 
variations  in  the  plans  of  conducting  schools.  The  Waltham  method 
is  good  because  its  work  is  so  thorough  and  earnest  that  it  is  a model 
for  its  purpose.  Every  large  asylum  for  the  insane,  with  its  consider- 
able population  long  resident,  has  its  hospital  cases.  With  a proper 
organization  of  a school  and  the  development  of  the  “hospital  idea,” 
the  charge  that  the  training  in  it  is  “one-sided”  cannot  be  sustained. 
There  is  bodily  nursing  enough  to  instruct  the  nurses  well  in  its  tech- 
nique. But,  above  all  things,  let  nothing  be  called  a “ school  ” unless 
it  is  thoroughly  organized  and  gives  a full  course,  amplifying  the 
didactic,  if  there  is  any  lack  of  practical  instruction.  There  is  one 
other  point  that  demands  broad-minded  consideration.  In  standing 
up  for  the  “ profession  ” of  nursing,  it  should  be  remembered  that  its 
work  cannot  be  limited  to  “ professionals,”  as  should  be  the  practice 
of  medicine : it  is  more  of  an  art  and  less  of  a science.  Let  all  j | 

teachers  master  its  scientific  side,  if  desirable ; but  the  art  of  nursing  I \ > 

consists  largely  of  what  every  mother  of  a family,  every  woman^xTl  \ 
should  know.  The  great  schools  will  claim  no  monopoly  of  this  + A \ 

knowledge : it  must  be  brought  down  to  the  people  for  whom  its  * 

attainment  is  most  difficult,  whose  need  must  longest  wait.  There  is 
an  element  of  common  education  in  it,  and  there  should  be  “ common 
schools  ” in  nursing  as  well  as  “ academies  ” \ and  there  is  the  high- 
est need  of  the  “university”  training  of  their  teachers.  It  should 
be  remembered  also  that  there  is  such  a thing  as  overtraining  women 
for  the  common  nursing, — this-will  never  be  done  by  the  relatively 
few  that  can  be  highly  trained.  The  more  the  people  are  trained 
to  know  of  these  things,  the  more  will  they  appreciate  and  exalt  in 
their  esteem  the  skilled  professional  rturse.  Any  question  of  the 
granting  of  diplomas  can  be  settled  as  we  go  along.  The  schools 
we  must  have. 

The  coming  of  this  new  dispensation  imposes  higher  .obligations 
upon  the  medical  profession  everywhere.  Now  that  there  is  shown  to 
be  a way  to  provide  “ trusty  agents,”  the  physician’s  duty  is  plainly 
greater  “ to  see  that  his  orders  are  intelligently  obeyed,”  as  Dr. 
Worcester  declares.  It  is  plain,  too,  that  physicians,  in  the  greater 
part,  must  “ train  their  own  nurses  ” ; and  it  is  shown  that  they  can 
do  it.  The  country  will  absorb  all  such  knowledge  that  can  be  given, 
and  all  the  trained  service  that  can  be  produced  by  the  two  new 
methods  here  advocated.  The  conditions  to  be  met  may  be  illus- 


6 


trated  by  a circumstance  that  has  recently  come  to  the  writer’s 
knowledge.  In  the  western  part  of  a large  Southern  State  on  the 
Atlantic  coast  there  is  a considerable  section  of  the  country  in  which 
the  only  woman  who  is  regarded  and  valued  as  having  any  qualifica- 
tion as  a nurse  is  one  who  was  for  a time  an  attendant  in  the  State 
Hospital  for  the  Insane.  It  is  obvious,  in  regard  to  her,  that  good 
training,  such  as  is  to  be  given  under  the  new  dispensation  now  be- 
ginning, would  have  greatly  enlarged  the  usefulness  and  accepta- 
bility of  this  nurse.  A like  neighboring  section  of  the  same  country 
has  furnished  a pupil  of  the  best  capacity  to  a Northern  Asylum 
School  for  Nurses,  from  which  she  may  return  to  be  a great  bless- 
ing to  her  native  State  if  the  opportunity  is  but  given  her, — per- 
haps in  a hospital  school.  Such  wide  fields  lie  open  and  waiting 
in  every  State,  where  there  may  be  an  uplifting  of  the  cause  of  hu- 
manity, and  of  the  scientific  treatment  of  the  sick  and  the  insane, 
through  the  inspiration  that  will  surely  flow  from  the  influence  of 
this  great  reform.  It  is  a reform  not  limited  in  its  deepening  and 
broadening  influence  to  the  service  of  nursing  the  sick,  noble  as 
that  may  be  : it  puts  into  the  hands  of  physicians  a new  order  of 
instruments, — intelligent  and  thinking, — that  teach  their  users.  The 
spirit  of  humanity  to  man  has  been  given  a new  embodiment. 


